Cassandra A. Stanton

Motivation and Patch Treatment for HIV+ Smokers: A Randomized Controlled Trial

AIMS To test the efficacy of two smoking cessation interventions in a HIV positive (HIV+) sample: standard care (SC) treatment plus nicotine replacement therapy (NRT) versus more intensive motivationally enhanced (ME) treatment plus NRT. DESIGN Randomized controlled trial. SETTING HIV+ smoker referrals from eight immunology clinics in the northeastern United States. PARTICIPANTS A total of 444 participants enrolled in the study (mean age = 42.07 years; 63.28% male; 51.80% European American; mean cigarettes/day = 18.27). INTERVENTIONS SC participants received two brief sessions with a health educator. Those setting a quit date received self-help quitting materials and NRT. ME participants received four sessions of motivational counseling and a quit-day counseling call. All ME intervention materials were tailored to the needs of HIV+ individuals. MEASUREMENTS Biochemically verified 7-day abstinence rates at 2-month, 4-month and 6-month follow-ups. FINDINGS Intent-to-treat (ITT) abstinence rates at 2-month, 4-month and 6-month follow-ups were 12%, 9% and 9%, respectively, in the ME condition, and 13%, 10% and 10%, respectively, in the SC condition, indicating no between-group differences. Among 412 participants with treatment utilization data, 6-month ITT abstinence rates were associated positively with low nicotine dependence (P = 0.02), high motivation to quit (P = 0.04) and Hispanic American race/ethnicity (P = 0.02). Adjusting for these variables, each additional NRT contact improved the odds of smoking abstinence by a third (odds ratio = 1.32, 95% confidence interval = 0.99-1.75). CONCLUSIONS Motivationally enhanced treatment plus NRT did not improve cessation rates over and above standard care treatment plus NRT in this HIV+ sample of smokers. Providers offering brief support and encouraging use of nicotine replacement may be able to help HIV+ patients to quit smoking.

Development and Reproducibility of a Brief Food Frequency Questionnaire for Assessing the Fat, Fiber, and Fruit and Vegetable Intakes of Rural Adolescents

OBJECTIVE To describe the systematic development and reproducibility of a food frequency questionnaire (FFQ) designed to meet the specific research requirements of the Goals for Health cancer prevention intervention program for rural middle school children. DESIGN A 4-step process was used to develop a brief FFQ for scoring intakes of total fat, fiber, and fruits and vegetables. The resulting questionnaire consisted of 25 food frequency items and 10 supplemental questions. Reproducibility of the questionnaire was determined by comparing responses at the beginning and end of a 4-month interval. SUBJECTS Study subjects were sixth- and seventh-grade students attending middle schools in rural areas of Virginia and upstate New York. Seventh-grade students participated in the pilot study, and sixth-grade students participated in the reproducibility study. The final version of the FFQ was completed twice by 539 sixth graders. After exclusions for missing and unreliable data, the usable sample size was 415. Boys were somewhat more likely than girls to be excluded for missing data. African-American students comprised 32% of the population. STATISTICAL ANALYSES PERFORMED Each food frequency item was associated with 3 scores--a fat score, a fiber score, and a combined score for the number of servings of fruits and vegetables. Means and standard deviations were determined for nutrient variables, differences between repeat administrations were tested for significance by paired t test, and Pearson correlation coefficients were calculated for nutrients and for individual food items. RESULTS Correlation coefficients for nutrient scores were 0.58 for fat, 0.49 for fiber, and 0.51 for fruits and vegetables. For individual food items, correlations ranged from 0.24 to 0.59 (mean=0.41). APPLICATIONS/CONCLUSIONS Using a systematic approach to developing a study-specific FFQ for rural adolescents is feasible. Further, the reproducibility of the Goals for Health questionnaire was demonstrated for the 3 nutrient scores it was designed to measure. This developmental approach may be readily adapted to other populations, study designs, and nutrients of interest. The validity of the questionnaire remains to be tested.

The association between alcohol, marijuana use, and new and emerging tobacco products in a young adult population.

BACKGROUND Young adults have the highest rates of alcohol, tobacco, and other drug use relative to any other age group. Few studies have examined the co-occurrence of substance use with new and emerging tobacco products in this vulnerable group, or the underlying personality factors that may explain these associations. To address this gap, this study examined the association of current alcohol and marijuana use with the use of cigarettes and emerging tobacco products in a nationally representative sample of young adults. METHODS Data were drawn from 18 to 24year olds in Wave 4 (January 2013; n=1609) of the Legacy Young Adult Cohort, a nationally-representative sample of men and women. Never, ever (lifetime), and past 30-day use of little cigars/cigarillos (LCCs), hookah, e-cigarettes, and cigarettes were assessed separately in current (everyday or some days) alcohol and marijuana users. RESULTS Using weighted estimates, multivariable multinomial logistic regression models showed that current alcohol and marijuana use were associated with lifetime and past 30-day use of cigarettes, LCCs, e-cigarettes, and hookah, with different magnitudes of association found across each product. Post-hoc exploratory analyses showed that sensation-seeking traits moderated the relationship of alcohol (but not marijuana) use to current use of select tobacco products. DISCUSSION Marijuana and alcohol use may enhance risk for emerging tobacco products use in young adulthood. Prevention and intervention programs may need to target poly-use of alcohol, marijuana, and tobacco rather than focusing on a single risk behavior during these critical years.

Adolescent tobacco use and substance abuse treatment outcomes

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters. Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.

Treatment-as-usual for adolescent suicide attempters: implications for the choice of comparison groups in psychotherapy research.

Studied Treatment-as-Usual (TAU) in a sample of 63 adolescent suicide attempters. Randomized clinical trials (RCTs) with high-risk populations, such as suicidal patients, are difficult to conduct due to clinical and ethical concerns about control groups. Therefore, TAU comparison groups have been proposed as ethically defensible alternatives to control groups. However, TAU is rarely characterized in treatment trials. Following a suicide attempt, the adolescents in our sample reported attending 0 to 22 outpatient psychotherapy sessions, with an average of 7.0 sessions. Fifty-two percent of the adolescents reported attending six or fewer sessions. Supportive psychotherapy techniques were reported by three fourths of the sample, psychodynamic and cognitive techniques by one half of the sample, and behavioral techniques by one third of the sample. Results suggest that TAU with this population of adolescents is highly variable, both in terms of the number of sessions attended and type of treatment received. This variability makes interpretation of treatment results in clinical trials with TAU comparison groups tenuous. Given the attention paid to treatment attendance and fidelity in most RCTs, even less potent control groups in such trials may be both ethically and clinically as justifiable as TAU designs for high-risk populations.

Mediators of the Relationship Between Nicotine Replacement Therapy and Smoking Abstinence Among People Living With HIV/AIDS

Cigarette smoking is highly prevalent among people living with HIV/AIDS and poses unique health risks. Smoking cessation programs tailored to this population have documented improved smoking outcomes with nicotine replacement therapy (NRT). The current study examined 6-month abstinence rates from a randomized clinical trial targeting 412 HIV-positive adult current smokers (51% European American, 19% African American, and 17% Hispanic American) and tested whether psychosocial variables, such as self-efficacy and decisional balance, mediated the relationship between NRT and long-term abstinence. Meeting criteria for complete mediation, 6-month smoking abstinence rates improved significantly with increases in these mediators, and the association of NRT and smoking abstinence was no longer significant once changes in self-efficacy and decisional balance were taken into account . Failure to translate gains in self-efficacy among African Americans into improved abstinence rates accounted for racial/ethnic differences among participants. Specific psychosocial factors, such as self-efficacy, may be particularly amenable to change in cessation interventions and should be addressed with greater awareness of how cultural and social contextual factors impact treatment response among people living with HIV/AIDS.

Flavored Tobacco Product Use in Youth and Adults: Findings From the First Wave of the PATH Study (2013-2014).

INTRODUCTION The 2009 Family Smoking Prevention and Tobacco Control Act banned characterizing flavors other than menthol in cigarettes but did not restrict their use in other forms of tobacco (e.g., smokeless, cigars, hookah, e-cigarettes). METHODS A cross-sectional analysis of Wave 1 data from 45,971 U.S. adults and youth, aged ≥12 years in the Population Assessment of Tobacco and Health (PATH) Study collected in 2013-2014, was conducted in 2016. This study examined (1) the prevalence and reasons for use of flavored tobacco products; (2) the proportion of ever tobacco users reporting that their first product was flavored; and (3) correlates of current flavored tobacco product use. RESULTS Current flavored (including menthol) tobacco product use was highest in youth (80%, aged 12-17 years); and young adult tobacco users (73%, aged 18-24 years); and lowest in older adult tobacco users aged ≥65 years (29%). Flavor was a primary reason for using a given tobacco product, particularly among youth. Eighty-one percent of youth and 86% of young adult ever tobacco users reported that their first product was flavored versus 54% of adults aged ≥25 years. In multivariable models, reporting that ones first tobacco product was flavored was associated with a 13% higher prevalence of current tobacco use among youth ever tobacco users and a 32% higher prevalence of current tobacco use among adult ever users. CONCLUSIONS These results add to the evidence base that flavored tobacco products may attract young users and serve as starter products to regular tobacco use.

Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: A randomized controlled trial

Objective:To evaluate the feasibility and preliminary efficacy of a Web-based tobacco treatment for persons living with HIV (PLWH). Design:Prospective, randomized controlled trial. Setting:HIV-care center in the Bronx, New York. Subjects:Eligibility criteria included HIV infection, current tobacco usage, interest in quitting, and access to a computer with internet. One hundred thirty-eight subjects enrolled, and 134 completed the study. Intervention:Positively Smoke Free on the Web (PSFW), an 8-session, 7-week targeted tobacco treatment program for PLWH, was compared with standard care (brief advice to quit and self-help brochure). All subjects were offered nicotine patches. Main Outcome Measures:The main feasibility outcomes were number of sessions logged into, number of Web pages visited, number of interactive clicks, and total time logged in. The main efficacy outcome was biochemically verified, 7-day point prevalence abstinence 3 months after intervention. Results:PSFW subjects logged into a mean of 5.5 of 8 sessions and 26.2 of 41 pages. They executed a mean of 10 interactive clicks during a mean total of 59.8 minutes logged in. Most required reminder phone calls to complete the sessions. Educational level, anxiety score, and home access of the Web site were associated with Web site usage. Ten percent of the PSFW group vs. 4.3% of controls achieved the abstinence end point. Among those who completed all 8 sessions, 17.9% were abstinent, and among women completers, 30.8% were abstinent. Conclusions:Web-based treatment is a feasible strategy for PLWH smokers, and preliminary findings suggest therapeutic efficacy.

Interventions to address chronic disease and HIV: strategies to promote smoking cessation among HIV-infected individuals.

Tobacco use, especially cigarette smoking, is higher than average in persons living with HIV/AIDS (PLWHA). The Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence states that, during every medical encounter, all smokers should be offered smoking cessation counseling, along with approved medications. The Guideline also recognizes PLWHA as a priority population, given the scarcity of research on effective cessation treatments in this group. The scant evidence suggests that conventional treatments, though worthwhile, are not as successful as might be hoped for. The reasons for this are not entirely clear, but may have to do with the complex array of medical and psychosocial factors that complicate their lives. Clinicians should consider re-treatment strategies for those patients who encounter difficulty when quitting smoking with conventional approaches, switching or augmenting treatments as needed to minimize adverse experiences, and to maximize tolerability, adherence, and cessation outcomes.

Racial and gender differences in the diets of rural youth and their mothers.

OBJECTIVE To examine mother-child dietary concordance that may contribute to healthy eating practices critical to cancer prevention in underserved rural families. METHODS A brief food frequency questionnaire was administered to 404 sixth-graders and their mothers in rural Virginia and New York. RESULTS Significant dietary fat concordance rates were indicated for mother-daughter dyads only. A 3-way interaction revealed that African American girls with mothers who report high fat intake are at highest risk for health-compromis ing dietary behaviors. CONCLUSIONS Interventions may need to differ entially motivate male and female adolescents and incorporate familial and cultural influences to pro mote healthy eating in rural youth.